A list of what is discussed in each chapter
NOTE ABOUT THIS NEW EDITION
WORDS TO THE VILLAGE HEALTH WORKER (Brown Pages). . . . . . . . . . . . . .w1
Health Needs and Human Needs w2 A Balance Between Prevention and
Many Thing Relate to Health Care w7 Treatment w17
Take a Good Look at Your Community w8 Sensible and Limited Use of Medicines w18
Using Local Resources to Meet Needs w12 Finding Out What Progress Has Been
Deciding What to Do and Where to Made w20
Begin w13 Teaching and Learning Together w21
Trying a New Idea w15 Tools for Teaching w22
A Balance Between People and Land w16 Making the Best Use of This Book w28
HOME CURES AND POPULAR BELIEFS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Home Cures That Help 1 Ways to Tell Whether a Home Remedy
Beliefs That Can Make People Well 2 Works or Not 10
Beliefs That Can Make People Sick 4 Medicinal Plants 12
Witchcraft—Black Magic—and the Evil Eye 5 Homemade Casts—for Broken Bones 14
Questions and Answers 6 Enemas, Laxatives, and Purges 15
Sunken Fontanel or Soft Spot 9
SICKNESSES THAT ARE OFTEN CONFUSED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
What Causes Sickness? 17 Example of Local Names for Sicknesses 22
Different Kinds of Sicknesses and Their Misunderstanding Due to Confusion of
Causes 18 Names 25
Non-infectious Diseases 18 Confusion between Different illnesses That
Infectious Diseases 19 Cause Fever 26
Sicknesses That Are Hard to Tell Apart 20
HOW TO EXAMINE A SICK PERSON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Questions 29 Eyes 33
General Condition of Health 30 Ears 34
Temperature 30 Skin 34
How to Use a Thermometer 31 The Belly (Abdomen) 35
Breathing (Respiration) 32 Muscles and Nerves 37
Pulse (Heartbeat) 32
HOW TO TAKE CARE OF A SICK PERSON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
The Comfort of the Sick Person 39 Watching for Changes 41
Special Care for a Person Who Is Very Ill 40 Signs of Dangerous Illness 42
Liquids 40 When and How to Look for Medical Help 43
Food 41 What to Tell the Health Worker 43
Cleanliness and Changing Position in Bed 41 Patient Report 44
HEALING WITHOUT MEDICINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Healing with Water 46
When Water Is Better than Medicines 47
RIGHT AND WRONG USE OF MODERN MEDICINES. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Guidelines for the Use of Medicine 49 When Should Medicine Not Be Taken? 54
The Most Dangerous Misuse of Medicine 50
ANTIBIOTICS: WHAT THEY ARE AND HOW TO USE THEM . . . . . . . . . . . . . . . . . . . . . . 55
Guidelines for the Use of Antibiotics 56
What to Do if an Antibiotic Does Not Seem to Help 57
Importance of Limited Use of Antibiotics 58
HOW TO MEASURE AND GIVE MEDICINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Medicine in Liquid Form 61 Dosage Instructions for Persons Who
How to Give Medicines to Small Children 62 Cannot Read 63
How to Take Medicines 63
INSTRUCTIONS AND PRECAUTIONS FOR INJECTIONS. . . . . . . . . . . . . . . . . . . . . . . . 65
When to Inject and When Not To 65 Avoiding Serious Reactions to Penicillin 71
Emergencies When It Is Important to Give How to Prepare a Syringe for Injection 72
Injections 66 How to Inject 73
Medicines Not to Inject 67 How Injections Can Disable Children 74
Risks and Precautions 68 How to Sterilize Equipment 74
Dangerous Reactions From Injecting Certain
FIRST AID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Infected Wounds 88 Protection 75
Basic Cleanliness and Infected Wounds 88
Fever Knife, and Other Serious Wounds 90 Bullet, Knife, and Other Serious Wounds 90
Emergency Problems of the Gut Emergency Problems of the Gut
of Consciousness 78
Loss (Acute Abdomen) 93 (Acute Abdomen) 93
Appendicitis, Peritonitis 94 in the
When Something Gets Stuck Appendicitis, Peritonitis 94
Burns 96 Throat 79 Burns 96
Broken Bones (Fractures) 98 Broken Bones (Fractures) 98
How to Move a Badly Injured Person 100
When Breathing Stops: Mouth-to-Mouth How to Move a Badly Injured Person 100
(Bones out of Place Heat 81
Emergencies Caused by at a Joint) 101 (Bones out of Place at a Joint) 101
Strains and Sprains 102 from a Wound 82
How to Control Bleeding Strains and Sprains 102
How to Stop Nosebleeds 83
CPoisoning 103 Poisoning 103
Snakebite 104 and Small Wounds 84
Cuts, Scrapes, Snakebite 104
Other Poisonous Bites andThem 85
Large Cuts: How to Close Stings 106 Other Poisonous Bites and Stings 106
NUTRITION: WHAT TO EAT TO BE HEALTHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Sicknesses Caused by Not Eating Well 107 Special Diets for Specific Health
Why It Is Important to Eat Right 109 Problems 124
Preventing Malnutrition 109 Anemia 124
Main Foods and Helper Foods 110 Rickets 125
Eating Right to Stay Healthy 111 High Blood Pressure 125
How to Recognize Malnutrition 112 Fat People 126
Eating Better When You Do Not Have Much Constipation 126
Money or Land 115 Diabetes 127
Where to Get Vitamins: In Pills or Acid Indigestion, Heartburn, and Stomach
in Foods? 118 Ulcers 128
Things to Avoid in Our Diet 119 Goiter
The Best Diet for Small Children 120 (A Swelling or Lump on the Throat) 130
Harmful Ideas about Diet 123
PREVENTION: HOW TO AVOID MANY SICKNESSES . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Cleanliness—and Problems from Lack of Trichinosis 144
Cleanliness 131 Amebas 144
Basic Guidelines of Cleanliness 133 Giardia 145
Sanitation and Latrines 137 Blood Flukes
Worms and Other Intestinal Parasites 140 (Schistosomiasis, Bilharzia) 146
Roundworm (Ascaris) 140 Vaccinations (lmmunizations)—Simple, Sure
Pinworm (Threadworm, Enterobius) 141 Protection 147
Whipworm (Trichuris) 142 Other Ways to Prevent Sickness and Injury 148
Hookworm 142 Habits That Affect Health 148
SOME VERY COMMON SICKNESSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Dehydration 151 Bronchitis 170
Diarrhea and Dysentery 153 Pneumonia 171
The Care of a Person with Acute Diarrhea 160 Hepatitis 172
Vomiting 161 Arthritis (Painful, Inflamed Joints) 173
Headaches and Migraines 162 Back Pain 173
Colds and the Flu 163 Varicose Veins 175
Stuffy and Runny Noses 164 Piles (Hemorrhoids) 175
Sinus Trouble (Sinusitis) 165 Swelling of the Feet and Other Parts of the
Hay Fever (Allergic Rhinitis) 165 Body 176
Allergic Reactions 166 Hernia (Rupture) 177
Asthma 167 Seizures (Fits, Convulsions) 178
SERIOUS ILLNESSES THAT NEED SPECIAL MEDICAL ATTENTION . . . . . . . . . . . .179
Tuberculosis (TB, Consumption) 179 Dengue (Breakbone Fever, Dandy
Rabies 181 Fever) 187
Tetanus (Lockjaw) 182 Brucellosis (Undulant Fever, Malta Fever) 188
Meningitis 185 Typhoid Fever 188
Malaria 186 Typhus 190
Leprosy (Hansen’s Disease) 191
SKIN PROBLEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193
General Rules for Treating Skin Problems 193 Warts (Verrucae) 210
Instructions for Using Hot Compresses 195 Corns 210
Identifying Skin Problems 196 Pimples and Blackheads (Acne) 211
Scabies 199 Cancer of the Skin 211
Lice 200 Tuberculosis of the Skin or Lymph
Bedbugs 200 Nodes 212
Ticks and Chiggers 201 Erysipelas and Cellulitis 212
Small Sores with Pus 201 Gangrene (Gas Gangrene) 213
Impetigo 202 Ulcers of the Skin Caused by Poor
Boils and Abscesses 202 Circulation 213
Itching Rash, Welts, or Hives 203 Bed Sores 214
Things That Cause Itching or Burning of the Skin Problems of Babies 215
Skin 204 Eczema
Shingles (Herpes Zoster) 204 (Red Patches with Little Blisters) 216
Ringworm, Tinea (Fungus Infections) 205 Psoriasis 216
White Spots on the Face and Body 206
Mask of Pregnancy 207
Pellagra and Other Skin Problems Due to
THE EYES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Danger Signs 217 Trouble Seeing Clearly 223
Injuries to the Eye 218 Cross-Eyes and Wandering Eyes 223
How to Remove a Speck of Dirt from the Sty (Hordeolum) 224
Eye 218 Pterygium 224
Chemical Burns of the Eye 219 A Scrape, Ulcer, or Scar on the Cornea 224
Red, Painful Eyes—Different Causes 219 Bleeding in the White of the Eye 225
‘Pink Eye’ (Conjunctivitis) 219 Bleeding behind the Cornea (Hyphema) 225
Trachoma 220 Pus behind the Cornea (Hypopyon) 225
Infected Eyes in Newborn Babies Cataract 225
(Neonatal Conjunctivitis) 221 Night Blindness and Xerophthalmia 226
Iritis (Inflammation of the Iris) 221 Spots or ‘Flies’ before the Eyes 227
Glaucoma 222 Double Vision 227
Infection of the Tear Sac River Blindness (Onchocerciasis) 227
THE TEETH, GUMS, AND MOUTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Care of Teeth and Gums 229 Sores or Cracks at the Corners of the
If You Do Not Have A Toothbrush 230 Mouth 232
Toothaches and Abscesses 231 White Patches or Spots in the Mouth 232
Pyorrhea, a Disease of the Gums 231 Cold Sores and Fever Blisters 232
THE URINARY SYSTEM AND THE GENITALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Urinary Tract Infections 234 Use of a Catheter to Drain Urine 239
Kidney or Bladder Stones 235 Problems of Women 241
Enlarged Prostate Gland 235 Vaginal Discharge 241
Diseases Spread by Sexual Contact How a Woman Can Avoid Many
(Sexually Transmitted Infections) 236 Infections 242
Gonorrhea (Clap, VD, the Drip) and Pain or Discomfort in a Woman’s Belly 243
Chlamydia 236 Men and Women Who Cannot Have Children
Syphilis 237 (Infertility) 244
Bubos: Bursting Lymph Nodes in the
INFORMATION FOR MOTHERS AND MIDWIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
The Menstrual Period How to Stay Healthy during Pregnancy 247
(Monthly Bleeding in Women) 245 Minor Problems during Pregnancy 248
The Menopause Danger Signs in Pregnancy 249
(When Women Stop Having Periods) 246 Check-ups during Pregnancy
Pregnancy 247 (Prenatal Care) 250
Record of Prenatal Care 253 Tearing of the Birth Opening 269
Things to Have Ready before the Birth 254 Care of the Newborn Baby 270
Preparing for Birth 256 Illnesses of the Newborn 272
Signs That Show Labor Is Near 258 The Mothers Health after Childbirth 276
The Stages of Labor 259 Childbirth Fever
Care of the Baby at Birth 262 (Infection after Giving Birth) 276
Care of the Cut Cord (Navel) 263 Care of the Breasts 277
The Delivery of the Placenta (Afterbirth) 264 Lumps or Growths in the Lower Part of the
Hemorrhaging (Heavy Bleeding) 264 Belly 280
The Correct Use of Oxytocics: Miscarriage (Spontaneous Abortion) 281
Ergonovine, Oxytocin, Pitocin, etc. 266 High Risk Mothers and Babies 282
Difficult Births 267
HAVING THE NUMBER OF CHILDREN YOU WANT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Choosing a method of Family Planning 284 Methods for Those Who Never Want to Have
Oral Contraceptives More Children 293
(Birth Control Pills) 286 Home Methods for Preventing
Other Methods of Family Planning 290 Pregnancy 294
Combined Methods 292
HEALTH AND SICKNESSES OF CHILDREN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
What to Do to Protect Children’s Mumps 312
Health 295 Whooping Cough 313
Children’s Growth— Diphtheria 313
and the ‘Road to Health’ 297 Infantile Paralysis (Polio) 314
Child Health Chart 298 How to Make Simple Crutches 315
Review of Children’s Health Problems Problems Children Are Born With 316
Discussed in Other Chapters 305 Dislocated Hip 316
Health Problems of Children Not Umbilical Hernia
Discussed in Other Chapters 309 (Belly Button That Sticks Out) 317
Earache and Ear Infections 309 A ‘Swollen Testicle’
Sore Throat and Inflamed Tonsils 309 (Hydrocele or Hernia) 317
Rheumatic Fever 310 Mentally Slow, Deaf, or Deformed
Infectious Diseases of Childhood 311 Children 318
Chickenpox 311 The Spastic Child (Cerebral Palsy) 320
Measles (Rubeola) 311 Retardation in the First Months of Life 321
German Measles (Rubella) 312 Sickle Cell Disease 321
Helping Children Learn 322
HEALTH AND SICKNESSES OF OLDER PEOPLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Summary of Health Problems Discussed in Deafness 327
Other Chapters 323 Loss of Sleep (Insomnia) 328
Other Important Illnesses of Old Age 325 Diseases Found More Often in People over
Heart Trouble 325 Forty 328
Words to Younger Persons Who Want to Cirrhosis of the Liver 328
Stay Healthy When Older 326 Gallbladder Problems 329
Stroke (Apoplexy, Cerebro-Vascular Accepting Death 330
Accident, CVA) 327
THE MEDICINE KIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
How to Care for Your Medicine Kit 332 The Village Medicine Kit 336
Buying Supplies for the Medicine Kit 333 Words to the Village Storekeeper
The Home Medicine Kit 334 (or Pharmacist) 338
THE GREEN PAGES—The Uses, Dosage, and Precautions for Medicines . . . . . . . 339
List of Medicines in the Green Pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
Index of Medicines in the Green Pages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
Information on Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
THE BLUE PAGES-New information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
HIV and AIDS 399 Guinea Worm 406
Sores on the Genitals 402 Emergencies Caused by Cold 408
Circumcision and Excision 404 How to Measure Blood Pressure 410
Special Care for Small, Early, Poisoning from Pesticides 412
and Underweight Babies 405 Complications from Abortion 414
Ear Wax 405 Drug Abuse and Addiction 416
VOCABULARY—Explaining Difficult Words . . . . . . . . . . . . . . . . . . . . . 419
ADDRESSES FOR TEACHING MATERIALS. . . . . . . . . . . . . . . . . . . . . . 429
INDEX (Yellow Pages) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
Dosage Instructions for Persons Who Cannot Read
Making Medical Reports
Information About Vital Signs
This handbook has been written primarily for those who live far from medical
centers, in places where there is no doctor. But even where there are doctors, people
can and should take the lead in their own health care. So this book is for everyone
who cares. It has been written in the belief that:
1. Health care is not only everyone’s right, but everyone’s responsibility.
2. Informed self-care should be the main goal of any health program or
3. Ordinary people provided with clear, simple information can prevent and
treat most common health problems in their own homes—earlier, cheaper,
and often better than can doctors.
4. Medical knowledge should not be the guarded secret of a select few, but
should be freely shared by everyone.
5. People with little formal education can be trusted as much as those with a
lot. And they are just as smart.
6. Basic health care should not be delivered, but encouraged.
Clearly, a part of informed self-care is knowing one’s own limits. Therefore
guidelines are included not only for what to do, but for when to seek help. The book
points out those cases when it is important to see or get advice from a health worker
or doctor. But because doctors or health workers are not always nearby, the book also
suggests what to do in the meantime—even for very serious problems.
This book has been written in fairly basic English, so that persons without much
formal education (or whose first language is not English) can understand it. The
language used is simple but, I hope, not childish. A few more difficult words have
been used where they are appropriate or fit well. Usually they are used in ways that
their meanings can be easily guessed. This way, those who read this book have a
chance to increase their language skills as well as their medical skills.
Important words the reader may not understand are explained in a word list or
vocabulary at the end of the book. The first time a word listed in the vocabulary is
mentioned in a chapter it is usually written in italics.
Where There Is No Doctor was first written in Spanish for farm people in the
mountains of Mexico where, 27 years ago, the author helped form a health care
network now run by the villagers themselves. Where There Is No Doctor has been
translated into more than 50 languages and is used by village health workers in over
The first English edition was the result of many requests to adapt it for use in Africa
and Asia. I received help and suggestions from persons with experience in many
parts of the world. But the English edition seems to have lost much of the flavor and
usefulness of the original Spanish edition, which was written for a specific area, and
for people who have for years been my neighbors and friends. In rewriting the book to
serve people in many parts of the world, it has in some ways become too general.
To be fully useful, this book should be adapted by persons familiar with the
health needs, customs, special ways of healing, and local language of specific
Persons or programs who wish to use this book, or portions of it, in preparing their
own manuals for villagers or health workers are encouraged to do so. Permission
from the author or publisher is not needed—provided the parts reproduced are
distributed free or at cost—not for profit. It would be appreciated if you would (1)
include a note of credit and (2) send a copy of your production to Hesperian, 1919
Addison St., #304, Berkeley, California 94704, U.S.A.
For local or regional health programs that do not have the resources for revising this
book or preparing their own manuals, it is strongly suggested that if the present edition
is used, leaflets or inserts be supplied with the book to provide additional information
In the Green Pages (the Uses, Dosage, and Precautions for Medicines) blank
spaces have been left to write in common brand names and prices of medicines.
Once again, local programs or organizations distributing the book would do well to
make up a list of generic or low-cost brand names and prices, to be included with
each copy of the book.
This book was written for anyone who wants to do something about his or her own
and other people’s health. However, it has been widely used as a training and work
manual for community health workers. For this reason, an introductory section has
been added for the health worker, making clear that the health worker’s first job is to
share her knowledge and help educate people.
Today in over-developed as well as under-developed countries, existing health care
systems are in a state of crisis. Often, human needs are not being well met. There is
too little fairness. Too much is in the hands of too few.
Let us hope that through a more generous sharing of knowledge, and through
learning to use what is best in both traditional and modern ways of healing, people
everywhere will develop a kinder, more sensible approach to caring—for their own
health, and for each other.
note about thIs new edItIon
In this revised edition of Where There is No Doctor, we have added new
information and updated old information, based on the latest scientific knowledge.
Health care specialists from many parts of the world have generously given advice
When it would fit without having to change page numbers, we have added new
information to the main part of the book. (This way, the numbering stays the same, so
that page references in our other books, such as Helping Health Workers Learn, will
still be correct.)
The Blue Pages—a section at the end of the book (p. 399)—has information about
health problems of growing or special concern: HIV/AIDS, sores on the genitals,
leishmaniasis, complications from abortion, guinea worm, and others. Here also are
new topics such as measuring blood pressure, misuse of pesticides, drug addiction,
and a method of caring for early and underweight babies.
New ideas and information can be found throughout the book—medical knowledge
is always changing! For example:
• Nutrition advice has changed. Experts used to tell mothers to give children
more foods rich in proteins. But it is now known that what most poorly nourished
children need is more energy-rich foods. Many low-cost energy foods, especially
grains, provide enough protein if the child eats enough of them. Finding ways to
give enough energy foods is now emphasized, instead of the ‘four food groups’.
(See Chapter 11.)
• Advice for treatment of stomach ulcer is different nowadays. For years doctors
recommended drinking lots of milk. But according to recent studies, it is better to
drink lots of water, not milk. (See p. 129.)
• Knowledge about special drinks for diarrhea (oral rehydration therapy) has
also changed. Not long ago experts thought that drinks made with sugar were
best. But we now know that drinks made with cereals do more to prevent water
loss, slow down diarrhea, and combat malnutrition than do sugar-based drinks or
“ORS” packets. (See p. 152.)
• A section has been added on sterilizing equipment. This is important to
prevent the spread of certain diseases, such as HIV/AIDS. (See p. 74.)
• We have also added sections on dengue (p. 187), sickle cell disease (p. 321),
and contraceptive implants (p. 293). Page 105 contains revised information
about treatment of snakebite.
• See page 139 for details on building the fly-killing VIP latrine.
If you have suggestions for improving this book, please
let us know. Your ideas are very important to us!
The Green Pages now include some additional medicines. This is because
some diseases have become resistant to the medicines that were used in the past.
So it is now harder to give simple medical advice for certain diseases—especially
malaria, tuberculosis, typhoid, and sexually spread diseases. Often we give several
possibilities for treatment. But for many infectious diseases you will need local
advice about which medicines are available and effective in your area.
In updating the information on medicines, we mostly include only those on the
World Health Organization’s List of Essential Drugs. (However we also discuss some
widely used but dangerous medicines to give warnings and to discourage their use—
see also pages 50 to 52.) In trying to cover health needs and variations in many parts
of the world, we have listed more medicines than will be needed for any one area. To
persons preparing adaptations of this book, we strongly suggest that the Green Pages
be shortened and modified to meet the specific needs and treatment patterns in your
In this new edition of Where There Is No Doctor we continue to stress the value of
traditional forms of healing, and have added some more “home remedies.” However,
since many folk remedies depend on local plants and customs, we have added only
a few which use commonly found items such as garlic. We hope those adapting this
book will add home remedies useful to their area.
Community action is emphasized throughout this book. For example, today it
is often not enough to explain to mothers that ‘breast is best’. Communities must
organize to make sure that mothers are able to breast feed their babies at work.
Likewise, problems such as misuse of pesticides (p. 412), drug abuse (p. 416), and
unsafe abortions (p. 414) are best solved by people working together to make their
communities safer, healthier, and more fair.
“Health for all” can be achieved only through the organized demand by
people for greater equality in terms of land, wages, services, and basic rights.
More power to the people!
Thanks to the work and dedication of
many groups and individuals around
the world, Where There Is No Doctor
has been translated into more than 80
languages. The following are some
of the translations and the addresses
where you can obtain them.
SPANISH and ENgLISH
editions are available from:
1919 Addison St., #304 • Berkeley, California 94704 • USA
www.hesperian.org • firstname.lastname@example.org
tel: (510) 845-4507 •fax: (510) 845-0539
Rotary Club of Dar es Salaam Health Learning Materials Ctr.
PO Box 1520 Institute of Medicine
Dar es Salaam P.O. Box 2533
TANZANIA Kathmandu, NEPAL
Arab Resource Collective Scientific Technology and
P.O. Box 13-5916 Language Institute (STLI)
Beirut, LEBANON P.O. Box 671
www.mawared.org Bishkek, 720017
B-40, Qutab Institutional Area URDU:
South of I.I.T. Pakistan Medical Association
New Delhi, 110 016 PMA House,Garden Road
INDIA Karachi 74400
INDONESIAN: HATIAN CREOLE:
Yayasan Essentia Medica Life Publishers International
PO Box 1058 1400 N. Campbell
Yogyakarta, 55010 Springfield MO 65902
INDONESIA UNITED STATES
Please write to Hesperian or look on our website at www.hesperian.org/publications_
translations.php for other editions including Albanian, Amharic, Aymara, Bengali, Burmese,
Cebuano, Chichewa, Chinese, Dari, Farsi, French, Fulfide, German, Ilongo, Italian,
Jinghpaw, Kannada, Karakalpak, Kazakh, Korean, Lao, Malayalam, Marathi, Marshallese,
Oriya, Portuguese, Pashto, Quechua, Somali, Tamil, Telegu, Thai, Tibetan, Tigrinya, Turkish,
Vietnamese, and Zulu, as well as other English editions adapted for specific countries.
We are looking for ways to get this book to those it can serve best. If you are able to
help or have suggestions, please contact Hesperian. We offer this book at a lower price to
persons of low income living in poor countries.
This revision of Where There Is No Doctor has been a cooperative effort. We thank the
many users of the book around the world who have written us over the years with comments and
suggestions—these have guided us in updating this information.
David Werner is the author of the original Spanish and English versions of the book. His vision,
caring, and commitment are present on every page. Carol Thuman and Jane Maxwell share credit
for most of the research, writing, and preparation of this revised version. We are deeply grateful
for their excellent and very careful work.
Thanks also to other researchers of this revised edition: Suellen Miller, Susan Klein, Ronnie
Lovich, Mary Ellen Guroy, Shelley Kahane, Paula Elster, and George Kent. For information from
the African edition, our thanks to Andrew Pearson and the other authors at Macmillan Publishers.
Many doctors and health care specialists from around the world generously reviewed portions
of the book. We cannot list them all here, but the help of the following was exceptional: David
Sanders, Richard Laing, Bill Bower, Greg Troll, Deborah Bickel, Tom Frieden, Jane Zucker, David
Morley, Frank Catchpool, Lonny Shavelson, Rudolph Bock, Joseph Cook, Sadja Greenwood,
Victoria Sheffield, Sherry Hilaski, Pam Zinkin, Fernando Viteri, Jordan Tapero, Robert Gelber,
Ted Greiner, Stephen Gloyd, Barbara Mintzes, Rainer Arnhold, Michael Tan, Brian Linde, Davida
Coady, and Alejandro de Avila. Their expert advice and help have been of great value.
We warmly thank the dedicated members of Hesperian for their help in preparing the
manuscript: Kyle Craven for computer graphic arts and layout, Stephen Babb and Cynthia
Roat for computer graphics, and Lisa de Avila for editorial assistance. We are also grateful to
many others who helped in this book’s preparation: Kathy Alberts, Mary Klein, Evan Winslow-
Smith, Jane Bavelas, Kim Gannon, Heidi Park, Laura Gibney, Nancy Ogaz, Martín Bustos, Karen
Woodbury, and Trude Bock. Our special thanks to Keith and Luella McFarland for being there
when we needed them most.
For help updating this book, we thank Manisha Aryal, Marcos Burgos, Pam Fadem, Iñaki
Fernández de Retana, Shu Ping Guan, Todd Jailer, Erika Leemann, Malcolm Lowe, Malini
Mahendra, Jane Maxwell, Susan McCallister, Gail McSweeney, Elena Metcalf, Syema Muzaffar,
Leana Rosetti, C. Sienkiewicz, Lora Santiago, Peter Small, Melissa Smith, Fred Strauss, Michael
Terry, Fiona Thomson, Kathleen Vickery, and Sarah Wallis. Todd Jailer coordinated this 2009
reprint with help from Elizabeth Babu, Dan Eisenberg, Jacob Goolkasian, Shu Ping Guan, Jane
Maxwell, Susan McCallister and Curt Wands.
Artwork for this book was created by David Werner, Kyle Craven, Shu Ping Guan, Susan Klein,
Regina Faul-Doyle, Sandy Frank, Fiona Thomson, and Lihua Wang. We also thank the following
persons and groups for permission to use their artwork: Dale Crosby, Carl Werner, Macmillan
Publishers (for some of Felicity Shepherd’s drawings in the African edition of this book), the “New
Internationalist” (for the picture of the VIP latrine), James Ogwang (for the drawings on page
417), and McGraw-Hill Book Company (for drawings appearing on pages 85 and 104 taken from
Emergency Medical Guide by John Henderson, illustrated by Niel Hardy).
The fine work of those who helped in the creation of the original version is still reflected on
nearly every page. Our thanks to Val Price, Al Hotti, Rodney Kendall, Max Capestany, Rudolf
Bock, Kent Benedict, Alfonzo Darricades, Carlos Felipe Soto Miller, Paul Quintana, David Morley,
Bill Bower, Allison Orozco, Susan Klein, Greg Troll, Carol Westburg, Lynn Gordon, Myra Polinger,
Trude Bock, Roger Buch, Lynne Coen, George Kent, Jack May, Oliver Bock, Bill Gonda, Ray
Bleicher, and Jesús Manjárrez.
For this 1992 edition, we are grateful for financial support from the Carnegie Corporation,
Gladys and Merrill Muttart Foundation, Myra Polinger, the Public Welfare Foundation, Misereor, the
W.K. Kellogg Foundation, the Sunflower Foundation, and the Edna McConnell Clark Foundation.
For this 2009 printing, thanks to Flora Family Foundation, Ford Foundation, Grousebeck Family
Foundation, Moriah Fund, and West Foundation.
Finally, our warm thanks to the village health workers of Project Piaxtla in rural Mexico
—especially Martín Reyes, Miguel Angel Manjárrez, Miguel Angel Alvarez, and Roberto Fajardo
whose experience and commitment have provided the foundation for this book.
Words to the Village health Worker
Who is the village health worker?
A village health worker is a person who helps lead family and neighbors toward
better health. Often he or she has been selected by the other villagers as someone
who is especially able and kind.
Some village health workers receive training and help from an organized
program, perhaps the Ministry of Health. Others have no official position, but are
simply members of the community whom people respect as healers or leaders in
matters of health. Often they learn by watching, helping, and studying on their own.
In the larger sense, a village health worker is anyone who takes part in
making his or her village a healthier place to live.
This means almost everyone can and should be a health worker:
• Mothers and fathers can show their children how to keep clean;
• Farm people can work together to help their land produce more food;
• Teachers can teach schoolchildren how to prevent and treat many common
sicknesses and injuries;
• Schoolchildren can share what they learn with their parents;
• Shopkeepers can find out about the correct use of medicines they sell and
give sensible advice and warning to buyers (see p. 338);
• Midwives can counsel parents
about the importance of eating
well during pregnancy, breast
feeding, and family planning.
This book was written for the
health worker in the larger sense.
It is for anyone who wants to
know and do more for his own, his
family’s or his people’s well-being.
If you are a community health
worker, an auxiliary nurse, or even a
doctor, remember: this book is not
just for you. It is for all the people.
Use this book to help explain
what you know to others. Perhaps
you can get small groups together
THE VILLAGE HEALTH WORKER LIVES AND
to read a chapter at a time and
WORKS AT THE LEVEL OF HIS PEOPLE. HIS
discuss it. FIRST JOB IS TO SHARE HIS KNOWLEDGE.
Where There Is No Doctor 2009
Dear Village Health Worker,
This book is mostly about people’s health needs. But to help your village be
a healthy place to live, you must also be in touch with their human needs. Your
understanding and concern for people are just as important as your knowledge of
medicine and sanitation.
Here are some suggestions that may
help you serve your people’s human
needs as well as health needs:
1. BE KIND. A friendly word, a smile, a
hand on the shoulder, or some other sign
of caring often means more than anything
else you can do. Treat others as your
equals. Even when you are hurried or
worried, try to remember the feelings and
needs of others. Often it helps to ask
yourself, “What would I do if this were a
member of my own family?”
Treat the sick as people. Be
especially kind to those who are very sick
or dying. And be kind to their families. Let Kindness often helps more than
medicine. Never be afraid to show
them see that you care. you care.
2. SHARE YOUR KNOWLEDGE. As a health worker, your first job is to teach. This
means helping people learn more about how to keep from getting sick. It also means
helping people learn how
to recognize and manage
their illnesses—including the
sensible use of home remedies
and common medicines.
There is nothing you have
learned that, if carefully
explained, should be of danger
to anyone. Some doctors talk
about self-care as if it were
dangerous, perhaps because
they like people to depend on
their costly services. But in
truth, most common health
problems could be handled
earlier and better by people
in their own homes.
LOOK FOR WAYS TO SHARE YOUR KNOWLEDGE
Where There Is No Doctor 2009
3. RESPECT YOUR PEOPLE’S TRADITIONS AND IDEAS.
Because you learn something about modern medicine does not mean you should
no longer appreciate the customs and ways of healing of your people. Too often the
human touch in the art of healing is lost when medical science moves in. This is too
bad, because. . .
If you can use what is best in modern medicine, together with what is best in
traditional healing, the combination may be better than either one alone.
In this way, you will be adding to your people’s culture, not taking away.
Of course, if you see that some of the home cures or customs are harmful (for
example, putting excrement on the freshly cut cord of a newborn baby), you will
want to do something to change this. But do so carefully, with respect for those
who believe in such things. Never just tell people they are wrong. Try to help them
understand WHY they should do something differently.
People are slow to change their attitudes and traditions, and with good reason.
They are true to what they feel is right. And this we must respect.
Modern medicine does not have all the answers either. It has helped solve some
problems, yet has led to other, sometimes even bigger ones. People quickly come to
depend too much on modern medicine and its experts, to overuse medicines, and
to forget how to care for themselves and each other.
So go slow—and always keep a deep respect for your people, their traditions,
and their human dignity. Help them build on the knowledge and skills they already
WORK WITH TRADITIONAL
HEALERS AND MIDWIVES—
NOT AGAINST THEM.
Learn from them
and encourage them
to learn from you.
Where There Is No Doctor 2009
4. KNOW YOUR OWN LIMITS.
No matter how great or small your
knowledge and skills, you can do a good
job as long as you know and work within
your limits. This means: Do what you
know how to do. Do not try things you
have not learned about or have not had
enough experience doing, if they might
harm or endanger someone.
But use your judgment.
Often, what you decide to do or not do
will depend on how far you have to go to
get more expert help.
For example, a mother has just
given birth and is bleeding more than
you think is normal. If you are only half
an hour away from a medical center,
it may be wise to take her there right KNOW YOUR LIMITS.
away. But if the mother is bleeding very
heavily and you are a long way from the health center, you may decide to massage her
womb (see p. 265) or inject an oxytocic (see p. 266) even if you were not taught this.
Do not take unnecessary chances. But when the danger is clearly greater if you do
nothing, do not be afraid to try something you feel reasonably sure will help.
Know your limits—but also use your head. Always do your best to protect the sick
person rather than yourself.
5. KEEP LEARNING.
Use every chance you have to learn more.
Study whatever books or information you can
lay your hands on that will help you be a better
worker, teacher, or person.
Always be ready to ask questions of doctors,
sanitation officers, agriculture experts, or
anyone else you can learn from.
Never pass up the chance to take refresher
courses or get additional training.
Your first job is to teach, and unless you
KEEP LEARNING—Do not let keep learning more, soon you will not have
anyone tell you there are things anything new to teach others.
you should not learn or know.
Where There Is No Doctor 2009
6. PRACTICE WHAT YOU TEACH.
People are more likely to pay attention to
what you do than what you say. As a health
worker, you want to take special care in your
personal life and habits, so as to set a good
example for your neighbors.
Before you ask people to make latrines, be
sure your own family has one.
Also, if you help organize a work group—
for example, to dig a common garbage
hole—be sure you work and sweat as hard as
Good leaders do not
tell people what to do.
They set the example.
PRACTICE WHAT YOU TEACH
(or who will listen to you?)
7. WORK FOR THE JOY OF IT.
If you want other people to take part in improving their village and caring for
their health, you must enjoy such activity yourself. If not, who will want to follow your
Try to make community work projects fun. For example, fencing off the public
water hole to keep animals away from where people take water can be hard work.
But if the whole village helps do it as a ‘work festival’—perhaps with refreshments
and music—the job
will be done quickly
and can be fun.
Children will work
hard and enjoy it, if
they can turn work
You may or may
not be paid for your
work. But never
refuse to care,
or care less, for
someone who is poor
or cannot pay.
This way you will
win your people’s WORK FIRST FOR THE PEOPLE—NOT THE MONEY.
love and respect. These (People are worth more.)
are worth far more than
Where There Is No Doctor 2009
8. LOOK AHEAD—AND HELP OTHERS TO LOOK AHEAD.
A responsible health worker does not wait for people to get sick. She tries to stop
sickness before it starts. She encourages people to take action now to protect their
health and well-being in the future.
Many sicknesses can be prevented. Your job, then, is to help your people
understand the causes of their health problems and do something about them.
Most health problems have many causes, one leading to another. To correct the
problem in a lasting way, you must look for and deal with the underlying causes. You
must get to the root of the problem.
For example, in many villages diarrhea is the most common cause of death in
small children. The spread of diarrhea is caused in part by lack of cleanliness (poor
sanitation and hygiene). You can do something to correct this by digging latrines and
teaching basic guidelines of cleanliness (p. 133).
But the children who suffer and die most often from diarrhea are those who
are poorly nourished. Their bodies do not have strength to fight the infections. So to
prevent death from diarrhea we must also prevent poor nutrition.
And why do so many children suffer from poor nutrition?
• Is it because mothers do not realize what foods are most important (for example,
• Is it because the family does not have enough money or land to produce the
food it needs?
• Is it because a few rich persons control most of the land and the wealth?
• Is it because the poor do
not make the best use of
land they have?
• Is it because parents have
more children than they or
their land can provide for,
and keep having more?
• Is it because fathers lose
hope and spend the little
money they have on drink?
• Is it because people do
not look or plan ahead?
Because they do not
realize that by working
together and sharing they
can change the conditions
under which they live and
HELP OTHERS TO LOOK AHEAD.
Where There Is No Doctor 2009
You may find that many, if not
all, of these things lie behind infant
deaths in your area. You will, no
doubt, find other causes as well. As
a health worker it is your job to help
people understand and do something
about as many of these causes as
But remember: to prevent frequent
deaths from diarrhea will take far
more than latrines, pure water, and
‘special drink’ (oral rehydration). You
may find that child spacing, better
land use, and fairer distribution of
wealth, land, and power are more
important in the long run.
The causes that lie behind much
sickness and human suffering are
short-sightedness and greed. If your
interest is your people’s well-being,
you must help them learn to share, to
work together, and to look ahead.
RELATE TO HEALTH CARE
We have looked at some of the causes
that underlie diarrhea and poor nutrition.
Likewise, you will find that such things
as food production, land distribution,
education, and the way people treat The chain of causes leading
or mistreat each other lie behind many to death from diarrhea.
different health problems.
If you are interested in the long-term welfare of your whole community, you
must help your people look for answers to these larger questions.
Health is more than not being sick. It is well-being: in body, mind, and
community. People live best in healthy surroundings, in a place where they can
trust each other, work together to meet daily needs, share in times of difficulty and
plenty, and help each other learn and grow and live, each as fully as he or she
Do your best to solve day-to-day problems. But remember that your greatest
job is to help your community become a more healthy and more human place to
You as a health worker have a big responsibility.
Where should you begin?
Where There Is No Doctor 2009
TAKE A GOOD LOOK AT YOUR COMMUNITY
Because you have grown up in your community and know your people well, you are
already familiar with many of their health problems. You have an inside view. But in
order to see the whole picture, you will need to look carefully at your community from
many points of view.
As a village health worker, your concern is for the well-being of all the people—not
just those you know well or who come to you. Go to your people. Visit their homes,
fields, gathering places, and schools. Understand their joys and concerns. Examine
with them their habits, the things in their daily lives that bring about good health, and
those that may lead to sickness or injury.
Before you and your community attempt any project or activity, carefully think about
what it will require and how likely it is to work. To do this, you must consider all the
1. Felt needs—what people feel are their biggest problems.
2. Real needs—steps people can take to correct these problems in a lasting way.
3. Willingness—or readiness of people to plan and take the needed steps.
4. Resources—the persons, skills, materials, and/or money needed to carry out the
activities decided upon.
As a simple example of how each of these things can be important, let us suppose
that a man who smokes a lot comes to you complaining of a cough that has steadily
been getting worse.
1. His felt need is to get rid of his cough. 2. His real need (to correct the problem)
is to give up smoking.
4. One resource that may help him give up
3. To get rid of his cough will require his smoking is information about the harm it can do
willingness to give up smoking. For this he him and his family (see p. 149). Another is the
must understand how much it really support and encouragement of his family, his
matters. friends, and you.
Where There Is No Doctor 2009
Finding Out the Needs
As a health worker, you will first want to find out your people’s most important
health problems and their biggest concerns. To gather the information necessary to
decide what the greatest needs and concerns really are, it may help to make up a
list of questions.
On the next 2 pages are samples of the kinds of things you may want to ask. But
think of questions that are important in your area. Ask questions that not only help
you get information, but that get others asking important questions themselves.
Do not make your list of questions too long or complicated—especially a list you
take from house to house. Remember, people are not numbers and do not like to
be looked at as numbers. As you gather information, be sure your first interest is
always in what individuals want and feel. It may be better not even to carry a list of
questions. But in considering the needs of your community, you should keep certain
basic questions in mind.
Where There Is No Doctor 2009
Sample Lists Of Questions
To Help Determine Community Health Needs
And at the Same Time Get People Thinking
What things in your people’s daily lives (living conditions, ways of doing things, beliefs,
etc.) do they feel help them to be healthy?
What do people feel to be their major problems, concerns, and needs—not only those
related to health, but in general?
HOUSING AND SANITATION
What are different houses made of? Walls? Floors? Are the houses kept clean? Is
cooking done on the floor or where? How does smoke get out? On what do people
Are flies, fleas, bedbugs, rats, or other pests a problem? In what way? What do people
do to control them? What else could be done?
Is food protected? How could it be better protected?
What animals (dogs, chickens, pigs, etc.), if any, are allowed in the house?
What problems do they cause?
What are the common diseases of animals? How do they affect people’s health? What is
being done about these diseases?
Where do families get their water? Is it safe to drink? What precautions are taken?
How many families have latrines? How many use them properly?
Is the village clean? Where do people put garbage? Why?
How many people live in the community? How many are under 15 years old?
How many can read and write? What good is schooling? Does it teach children what
they need to know? How else do children learn?
How many babies were born this year? How many people died? Of what? At what
ages? Could their deaths have been prevented? How?
Is the population (number of people) getting larger or smaller? Does this cause any
How often were different persons sick in the past year? How many days was each sick?
What sickness or injuries did each have? Why?
How many people have chronic (long-term) illnesses? What are they?
How many children do most parents have? How many children died? Of what? At what
ages? What were some of the underlying causes?
How many parents are interested in not having any more children or in not having them
so often? For what reasons? (See Family Planning, p. 283.)
Where There Is No Doctor 2009
How many mothers breast feed their babies? For how long? Are
these babies healthier than those who are not breast fed? Why?
What are the main foods people eat? Where do they come from?
Do people make good use of all foods available?
How many children are underweight (p. 109) or show signs of poor nutrition? How
much do parents and school children know about nutritional needs?
How many people smoke a lot? How many drink alcoholic or soft drinks very often?
What effect does this have on their own and their families’ health?
(See p. 148 to 150.)
LAND AND FOOD
Does the land provide enough food for each family?
How long will it continue to produce enough food if families keep growing?
How is farm land distributed? How many people own their land?
What efforts are being made to help the land produce more?
How are crops and food stored? Is there much damage or loss? Why?
What role do local midwives and healers play in health care?
What traditional ways of healing and medicines are used?
Which are of greatest value? Are any harmful or dangerous?
What health services are nearby? How good are they? What do they cost? How
much are they used?
How many children have been vaccinated? Against what sicknesses?
What other preventive measures are being taken? What others might be taken?
How important are they?
What are the most important things that affect your
people’s health and well-being—now and in the future?
How many of their common health problems can people care
for themselves? How much must they rely on outside help and medication?
Are people interested in finding ways of making self-care safer, more effective and
more complete? Why? How can they learn more? What stands in the way?
What are the rights of rich people? Of poor people? Of men? Of women?
Of children? How is each of these groups treated? Why? Is this fair? What needs to
be changed? By whom? How?
Do people work together to meet common needs? Do they share or help each other
when needs are great?
What can be done to make your village a better, healthier place to live? Where might
you and your people begin?
Where There Is No Doctor 2009
USING LOCAL RESOURCES TO MEET NEEDS
How you deal with a problem will depend upon what resources are available.
Some activities require outside resources (materials, money, or people from
somewhere else). For example, a vaccination program is possible only if vaccines are
brought in—often from another country.
Other activities can be carried out completely with local resources. A family or a
group of neighbors can fence off a water hole or build simple latrines using materials
close at hand.
Some outside resources, such as vaccines and a few important medicines, can
make a big difference in people’s health. You should do your best to get them. But as a
general rule, it is in the best interest of your people to
Use local resources whenever possible.
The more you and your Encourage people to make
people can do for yourselves, the most of local resources.
and the less you have to
depend on outside assistance
and supplies, the healthier and
stronger your community will
Not only can you count on
local resources to be on hand
when you need them, but often
they do the best job at the
lowest cost. For example, if
you can encourage mothers to
breast feed their babies, this
will build self-reliance through
a top quality local resource—
breast milk! It will also prevent
needless sickness and death
of many babies. BREAST MILK—A TOP QUALITY
LOCAL RESOURCE—BETTER THAN
In your health work always ANYTHING MONEY CAN BUY!
The most valuable resource for the health of the people is the
Where There Is No Doctor 2009
DECIDING WHAT TO DO AND WHERE TO BEGIN
After taking a careful look at needs and resources, you and your people must
decide which things are more important and which to do first. You can do many
different things to help people be healthy. Some are important immediately. Others
will help determine the future well-being of individuals or the whole community.
In a lot of villages, poor nutrition plays a part in other health problems. People
cannot be healthy unless there is enough to eat. Whatever other problems you
decide to work with, if people are hungry or children are poorly nourished, better
nutrition must be your first concern.
There are many different ways to approach the problem of poor nutrition, for
many different things join to cause it. You and your community must consider the
possible actions you might take and decide which are most likely to work.
Here are a few examples of ways some people have helped meet their needs for
better nutrition. Some actions bring quick results. Others work over a longer time.
You and your people must decide what is most likely to work in your area.
POSSIBLE WAYS TO WORK TOWARD BETTER NUTRITION
FAMILY GARDENS CONTOUR DITCHES
to prevent soil from
ROTATION OF CROPS
Every other planting season plant a crop that returns strength to the soil—like beans, peas, lentils, alfalfa,
peanuts or some other plant with seed in pods (legumes).
This year maize Next year beans
Where There Is No Doctor 2009
MORE WAYS TO WORK TOWARD BETTER NUTRITION
IRRIGATION OF LAND FISH BREEDING
BEEKEEPING NATURAL FERTILIZERS
BETTER FOOD SMALLER FAMILIES
THROUGH FAMILY PLANNING
Where There Is No Doctor 2009
TRYING A NEW IDEA
Not all the suggestions on the last pages are
likely to work in your area. Perhaps some will work if
changed for your particular situation and resources
at hand. Often you can only know whether
something will work or not by trying it. That is, by
When you try out a new idea, always start
small. If you start small and the experiment fails,
or something has to be done differently, you will not
lose much. If it works, people will see that it works
and can begin to apply it in a bigger way.
Do not be discouraged if an experiment does not work. Perhaps you can try
again with certain changes. You can learn as much from your failures as your
successes. But start small.
Here is an example of experimenting with a new idea.
You learn that a certain kind of bean, such as soya, is an excellent body-building
food. But will it grow in your area? And if it grows, will people eat it?
Start by planting a small patch—or 2 or 3 small patches in different conditions of soil
or water. If the beans do well, try preparing them in different ways, and see if people
will eat them. If so, try planting more beans in the conditions where you found they grew
best. But try out still other conditions in more small patches to see if you can get an even
There may be several conditions you want to try changing. For example, type
of soil, addition of fertilizer, amount of water, or different varieties of seed. To best
understand what helps and what does not, be sure to change only one condition at
a time and keep all the rest the same.
For example, to find out if animal fertilizer (manure) helps the beans grow, and how
much to use, plant several small bean patches side by side, under the same conditions
of water and sunlight, and using the same seed. But before you plant, mix each patch
with a different amount of manure, something like this:
This experiment shows that a certain amount of manure helps, but that too much
can harm the plants. This is only an example. You experiments may give different
results. Try for yourself!
Where There Is No Doctor 2009
WORKING TOWARD A BALANCE BETWEEN
PEOPLE AND LAND
Health depends on many things, but above all it depends on whether people have
enough to eat.
Most food comes from the land. Land that is used well can produce more food. A
health worker needs to know ways to help the land better feed the people—now and
in the future. But even the best used piece of land can only feed a certain number of
people. And today, many of the people who farm do not have enough land to meet
their needs or to stay healthy.
In many parts of the world, the situation is getting worse, not better. Parents often
have many children, so year by year there are more mouths to feed on the limited land
that the poor are permitted to use.
Many health programs try to work toward a balance between people and land
through ‘family planning,’ or helping people have only the number of children they
want. Smaller families, they reason, will mean more land and food to go around. But
family planning by itself has little effect. As long as people are very poor, they often
want many children. Children help with work without having to be paid, and as they
get bigger may even bring home a little money. When the parents grow old, some of
their children—or grandchildren—will perhaps be able to help care for them.
For a poor country to have many children may be an economic disaster. But for a
poor family to have many children is often an economic necessity—especially when
many die young. In the world today, for most people, having many children is the
surest form of social security they can hope for.
Some groups and programs take a different approach. They recognize that hunger
exists not because there is too little land to feed everyone, but because most of
the land is in the hands of a few selfish persons. The balance they seek is a fairer
distribution of land and wealth. They work to help people gain greater control over
their health, land, and lives.
It has been shown that, where land and wealth are shared more fairly and people
gain greater economic security, they usually choose to have smaller families. Family
planning helps when it is truly the people’s choice. A balance between people and
land can more likely be gained through helping people work toward fairer distribution
and social justice than through family planning alone.
It has been said that the social meaning of love is justice. The health worker who
loves her people should help them work toward a balance based on a more just
distribution of land and wealth.
Where There Is No Doctor 2009
WORKING TOWARD A
A balance between treatment and prevention often comes down to a balance
between immediate needs and long-term needs.
As a health worker you must go to your people, work with them on their terms,
and help them find answers to the needs they feel most. People’s first concern is
often to find relief for the sick and suffering. Therefore, one of your first concerns
must be to help with healing.
But also look ahead. While caring for people’s immediate felt needs, also help
them look to the future. Help them realize that much sickness and suffering can be
prevented and that they themselves can take preventive actions.
But be careful! Sometimes health planners and workers go too far. In their
eagerness to prevent future ills, they may show too little concern for the sickness
and suffering that already exist. By failing to respond to people’s present needs, they
may fail to gain their cooperation. And so they fail in much of their preventive work
Treatment and prevention go hand in hand. Early treatment often prevents
mild illness from becoming serious. If you help people to recognize many of
their common health problems and to treat them early, in their own homes, much
needless suffering can be prevented.
Early treatment is a form of preventive medicine.
If you want their cooperation, start where your people are. Work toward a
balance between prevention and treatment that is acceptable to them. Such a
balance will be largely determined by people’s present attitudes toward sickness,
healing, and health. As you help them look farther ahead, as their attitudes change,
and as more diseases are controlled, you may find that the balance shifts naturally in
favor of prevention.
You cannot tell the mother whose child is ill that prevention is more important than
cure. Not if you want her to listen. But you can tell her, while you help her care for her
child, that prevention is equally important.
Work toward prevention—do not force it.
Use treatment as a doorway to prevention. One of the best times to talk to
people about prevention is when they come for treatment. For example, if a mother
brings a child with worms, carefully explain to her how to treat him. But also take
time to explain to both the mother and child how the worms are spread and the
different things they can do to prevent this from happening (see Chapter 12). Visit
their home from time to time, not to find fault, but to help the family toward more
Use treatment as a chance to teach prevention.
Where There Is No Doctor 2009
SENSIBLE AND LIMITED USE OF MEDICINES
One of the most difficult and important parts of preventive care is to educate
your people in the sensible and limited use of medicines. A few modern medicines
are very important and can save lives. But for most sicknesses no medicine is
needed. The body itself can usually fight off sickness with rest, good food, drinking
lots of liquid, and perhaps some simple home remedies.
People may come to you asking for medicine when they do not need any. You
may be tempted to give them some medicine just to please. But if you do, when
they get well, they will think that you and the medicine cured them. Really their
bodies cured themselves.
Instead of teaching people to depend on medicines they do not need, take
time to explain why they should not be used. Also tell people what they can do
themselves to get well.
This way you are helping people to rely on local resources (themselves), rather
than on an outside resource (medicine). Also, you are protecting their health, for
there is no medicine that does not have some risk in its use.
Three common health problems for which people too often request medicines
they do not need are (1) the common cold, (2) minor cough, and (3) diarrhea.
The common cold is best treated by resting, drinking lots of liquids, and at the
most taking aspirin. Penicillin, tetracycline, and other antibiotics do not help at all
(see p. 163).
For minor coughs, or even more severe coughs with thick mucus or phlegm,
drinking a lot of water will loosen mucus and ease the cough faster and better
than cough syrup. Breathing warm water vapor brings even greater relief (see p.
168). Do not make people dependent on cough syrup or other medicines they do
For most diarrhea of children, medicines do not make them get well. Many
commonly used medicines (neomycin, streptomycin, kaolin-pectin, Lomotil,
chloramphenicol) may even be harmful. What is most important is that the child
get lots of liquids and enough food (see p. 155 to 156). The key to the child’s
recovery is the mother, not the medicine. If you can help mothers understand this
and learn what to do, many children’s lives can be saved.
Where There Is No Doctor 2009
Medicines are often used too much, both by doctors and by ordinary people.
This is unfortunate for many reasons:
• It is wasteful. Most money spent on medicine would be better spent on food.
• It makes people depend on something they do not need (and often cannot
• Every medicine has some risk in its use. There is always a chance that an
unneeded medicine may actually do the person harm.
• What is more, when some medicines are used too often for minor problems,
they lose their power to fight dangerous sicknesses.
An example of a medicine losing its power is chloramphenicol. The extreme
overuse of this important but risky antibiotic for minor infections has meant that in
some parts of the world chloramphenicol no longer works against typhoid fever, a
very dangerous infection. Frequent overuse of chloramphenicol has allowed typhoid
to become resistant to it (see p. 58).
For all the above reasons the use of medicines should be limited.
But how? Neither rigid rules and restrictions nor permitting only highly trained
persons to decide about the use of medicines has prevented overuse. Only when
the people themselves are better informed will the limited and careful use of
medicines be common.
To educate people about sensible and limited use of medicines
is one of the important jobs of the health worker.
This is especially true in areas where modern medicines are already in great
WHEN MEDICINES ARE NOT NEEDED, TAKE TIME TO EXPLAIN WHY.
For more information about the use and misuse of medicines, see Chapter
6, page 49. For the use and misuse of injections, see Chapter 9, page 65. For
sensible use of home remedies, see Chapter 1.
Where There Is No Doctor 2009
FINDING OUT WHAT PROGRESS HAS BEEN MADE
From time to time in your health work, it helps to take a careful look at what and how
much you and your people have succeeded in doing. What changes, if any, have been
made to improve health and well-being in your community?
You may want to record each month or year the health activities that can be
measured. For example:
• How many families have put in latrines?
• How many farmers take part in activities to improve their land and crops?
• How many mothers and children take part in an Under-Fives Program (regular
check-ups and learning)?
This kind of question will help you measure action taken. But to find out
the result or impact of these activities on health, you will need to answer other
questions such as:
• How many children had diarrhea or signs of worms in the past month or year—as
compared to before there were latrines?
• How much was harvested this season (corn, beans, or other crops)—as compared
to before improved methods were used?
• How many children show normal weight and weight-gain on their Child Health
Charts (see p. 297)—as compared to when the Under-Fives Program was started?
• Do fewer children die now than before?
To be able to judge the success of any activity you need to collect certain
information both before and after. For example, if you want to teach mothers how
important it is to breast feed their babies, first take a count of how many mothers are
doing so. Then begin the teaching program and each year take another count. This
way you can get a good idea as to how much effect your teaching has had.
You may want to set goals. For example, you and the health committee may hope
that 80% of the families have latrines by the end of one year. Every month you take a
count. If, by the end of six months, only one-third of the families have latrines, you know
you will have to work harder to meet the goal you set for yourselves.
Setting goals often helps people work harder and get more done.
To evaluate the results of your health activities it helps to count and measure certain
things before, during, and after.
But remember: The most important part of your health work cannot be
measured. It has to do with the way you and other people relate to each other; with
people learning and working together; with the growth of kindness, responsibility,
sharing, and hope. It depends on the growing strength and unity of the people to stand
up for their basic rights. You cannot measure these things. But weigh them well when
you consider what changes have been made.
Where There Is No Doctor 2009
TEACHING AND LEARNING TOGETHER—
THE HEALTH WORKER AS AN EDUCATOR
As you come to realize how many things affect health, you may think the health
worker has an impossibly large job. And true, you will never get much done if you try
to deliver health care by yourself.
Only when the people themselves become actively responsible for their own
and their community’s health, can important changes take place.
Your community’s well-being depends on the involvement not of one person,
but of nearly everyone. For this to happen, responsibility and knowledge must be
This is why your first job as a health worker is to teach—to teach children,
parents, farmers, schoolteachers, other health workers—everyone you can.
The art of teaching is the most important skill a person can learn. To teach is to
help others grow, and to grow with them. A good teacher is not someone who
puts ideas into other people’s heads; he or she is someone who helps others
build on their own ideas, to make new discoveries for themselves.
Teaching and learning should not be limited to the schoolhouse or health post.
They should take place in the home and in the fields and on the road. As a health
worker one of your best chances to teach will probably be when you treat the sick.
But you should look for every opportunity to exchange ideas, to share, to show, and
to help your people think and work together.
On the next few pages are some ideas that may help you do this. They are only
suggestions. You will have many other ideas yourself.
TWO APPROACHES TO HEALTH CARE
Where There Is No Doctor 2009
Tools for Teaching
Flannel-graphs are good for talking with groups
because you can keep making new pictures. Cover a
square board or piece of cardboard with a flannel cloth.
You can place different cutout drawings or photos on
it. Strips of sandpaper or flannel glued to the backs of
cutouts help them stick to the flannelboard.
Posters and displays. “A picture is worth a
thousand words.” Simple drawings, with or without a
few words of information, can be hung in the health
post or anywhere that people will look at them. You can
copy some of the pictures from this book.
If you have trouble getting sizes and shapes right,
draw light, even squares in pencil over the picture
you want to copy.
Now draw the same number of squares lightly,
but larger, on the poster paper or cardboard. Then
copy the drawing, square for square.
If possible, ask village artists to draw or paint
posters. Or have children make posters on different
Models and demonstrations help get ideas across.
For example, if you want to talk with mothers and midwives
about care in cutting the cord of a newborn child, you
can make a doll for the baby. Pin a cloth cord to its belly.
Experienced midwives can demonstrate to others.
Color slides and filmstrips are available on different
health subjects for many parts of the world. Some come in
sets that tell a story. Simple viewers and battery-operated
projectors are also available.
A list of addresses where you can send for teaching materials to use for health
education in your village can be found on pages 429 to 432.
Where There Is No Doctor 2009
Other Ways to Get Ideas Across
Story telling. When you have a hard time explaining something, a story,
especially a true one, will help make your point.
For example, if I tell you that sometimes a village worker can make a better
diagnosis than a doctor, you may not believe me. But if I tell you about a village
health worker called Irene, who runs a small nutrition center in Central America, you
One day a small sickly child arrived at the nutrition center. He had been sent by the
doctor at a nearby health center because he was badly malnourished. The child also had
a cough, and the doctor had prescribed a cough medicine. Irene was worried about the
child. She knew he came from a very poor family and that an older brother had died a few
weeks before. She went to visit the family and learned that the older brother had been
very sick for a long time and had coughed blood. Irene went to the health center and told
the doctor she was afraid the child had tuberculosis. Tests were made, and it turned out
that Irene was right. . . . So you see, the health worker spotted the real problem before the
doctor—because she knew her people and visited their homes.
Stories also make learning more interesting. It helps if health workers are good
Play acting. Stories that make important points can reach people with even
more force if they are acted out. Perhaps you, the schoolteacher, or someone on the
health committee can plan short plays or ‘skits’ with the schoolchildren.
For example, to make the
point that food should be
protected from flies to prevent
the spread of disease, several
small children could dress up as
flies and buzz around food. The
flies dirty the food that has not
been covered. Then children eat
this food and get sick. But the
flies cannot get at food in a box
with a wire screen front. So the
children who eat this food stay
The more ways you can find to share ideas,
the more people will understand and remember.
Where There Is No Doctor 2009
Working and Learning Together for the Common Good
There are many ways to interest and involve people in working together to meet their
common needs. Here are a few ideas:
1. A village health committee. A group of able, interested persons can be
chosen by the village to help plan and lead activities relating to the well-being of the
community—for example, digging garbage pits or latrines. The health worker can and
should share much of his responsibility with other persons.
2. Group discussions. Mothers, fathers, schoolchildren, young people, folk healers,
or other groups can discuss needs and problems that affect health. Their chief purpose
can be to help people share ideas and build on what they already know.
3. Work festivals.
Community projects such
as putting in a water system
or cleaning up the village go quickly
and can be fun if everybody helps.
Games, races, refreshments, and
simple prizes help turn work into play.
4. Cooperatives. People can help
keep prices down by sharing tools,
storage, and perhaps land. Group
cooperation can have a big influence
on people’s well-being.
5. Classroom visits. Work with the village schoolteacher to encourage health-related
activities, through demonstrations and play acting. Also invite small groups of students
to come to the health center. Children not only learn quickly, but they can help out in
many ways. If you give children a chance, they gladly become a valuable resource.
6. Mother and child health meetings. It is especially important that pregnant women
and mothers of small children (under five years old) be well informed about their own
and their babies’ health needs. Regular visits to the health post are opportunities for
both check-ups and learning. Have mothers keep their children’s health records and
bring them each month to have their children’s growth recorded (see the Child Health
Chart, p. 297). Mothers who understand the chart often take pride in making sure their
children are eating and growing well. They can learn to understand these charts even if
they cannot read. Perhaps you can help train interested mothers to organize and lead
7. Home visits. Make friendly visits to people’s homes, especially homes of families
who have special problems, who do not come often to the health post, or who do
not take part in group activities. But respect people’s privacy. If your visit cannot be
friendly, do not make it—unless children or defenseless persons are in danger.
Where There Is No Doctor 2009
Ways to Share and Exchange Ideas in a Group
As a health worker you will find that the success you have in improving your
people’s health will depend far more on your skills as a teacher than on your
medical or technical knowledge. For only when the whole community is involved
and works together can big problems be overcome.
People do not learn much from what they are told. They learn from what they
think, feel, discuss, see, and do together.
So the good teacher does not sit behind a desk and talk at people. He talks and
works with them. He helps his people to think clearly about their needs and to find
suitable ways to meet them. He looks for every opportunity to share ideas in an
open and friendly way.
Perhaps the most important thing you can do as a health worker is to awaken
your people to their own possibilities. . . to help them gain confidence in themselves.
Sometimes villagers do not change things they do not like because they do not
try. Too often they may think of themselves as ignorant and powerless. But they
are not. Most villagers, including those who cannot read or write, have remarkable
knowledge and skills. They already make great changes in their surroundings with
the tools they use, the land they farm, and the things they build. They can do many
important things that people with a lot of schooling cannot.
If you can help people realize how much they already know and have done
to change their surroundings, they may also realize that they can learn and do
even more. By working together it is within their power to bring about even bigger
changes for their health and well-being.
Then how do you tell people these things?
Often you cannot! But you can help them find out some of these things for
themselves—by bringing them together for discussions. Say little yourself, but start
the discussion by asking certain questions. Simple pictures like the drawing on
the next page of a farm family in Central America may help. You will want to draw
your own picture, with buildings, people, animals, and crops that look as much as
possible like those in your area.
Where There Is No Doctor 2009
USE PICTURES TO GET PEOPLE TALKING AND THINKING TOGETHER
Show a group of people a picture similar to this and ask them to discuss it. Ask
questions that get people talking about what they know and can do. Here are some
• Who are the people in the picture and how do they live?
• What was this land like before the people came?
• In what ways have they changed their surroundings?
• How do these changes affect their health and well-being?
• What other changes could these people make? What else could they learn to do?
What is stopping them? How could they learn more?
• How did they learn to farm? Who taught them?
• If a doctor or a lawyer moved onto this land with no more money or tools than
these people, could he farm it as well? Why or why not?
• In what ways are these people like ourselves?
Where There Is No Doctor 2009
This kind of group discussion helps build people’s confidence in themselves and
in their ability to change things. It can also make them feel more involved in their
At first you may find that people are slow to speak out and say what they think.
But after a while they will usually begin to talk more freely and ask important
questions themselves. Encourage everyone to say what he or she feels and to
speak up without fear. Ask those who talk most to give a chance to those who are
slower to speak up.
You can think of many other drawings and questions to start discussions that can
help people look more clearly at problems, their causes, and possible solutions.
What questions can you ask to get people thinking about the different things that
lead to the condition of the child in the following picture?
Try to think of questions that lead to others and get people asking for themselves.
How many of the causes underlying death from diarrhea (see p. w7) will your
people think of when they discuss a picture like this?